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Nathaniel S, Oleru O, Seyidova N, Levy L, Taub PJ, Horesh E. Vaginal Reconstruction in the Pediatric Population: An Analysis of a National Database. J Pediatr Surg 2023; 58:2405-2409. [PMID: 37633769 PMCID: PMC11000433 DOI: 10.1016/j.jpedsurg.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE In the pediatric population, vaginoplasties can be performed in patients with either congenital malformations or acquired conditions. To our knowledge, there has been no study to date investigating the outcomes of vaginoplasty in the pediatric population using a nationwide database. Here, we present a national cohort study of perioperative characteristics and 30-day complications of vaginoplasty in pediatric patients. METHODS A level II retrospective, prognosis cohort study was performed using the Pediatric National Surgical Quality Improvement Program (NSQIP-P) database from 2012 to 2020. Data from patients age 0 to 18 who underwent vaginoplasty was queried using CPT code 57,335. Descriptive analysis was performed to elucidate patterns in patient demographics, perioperative characteristics, and 30-day postoperative outcomes. RESULTS A total of 183 patients were identified. Median age was 2.41 years (IQR 0.9 to 12.1). In this population, 58.5% of patients had ASA class 2, and 33.3% ASA class 3. Congenital malformation was present in 75.9%. Average total length of stay was 2.7 days (SD = 3.8) and readmission rate was 7.86%. Complications included urinary tract infection (3.3%), bleeding/transfusions (2.2%), organ/space surgical site infection (1.1%), and superficial incisional surgical site infection (0.6%). The most common procedures performed simultaneously with vaginoplasty included cystourethroscopy (n = 66), clitoroplasty for intersex state (n = 58), and plastic repair of introitus (n = 22). CONCLUSION Vaginoplasties in the pediatric population were found to have low rates of 30-day readmission and low incidence of 30-day postoperative complications. Further studies focusing on prospective clinical data related to pediatric vaginoplasty can help identify factors to improve long-term outcomes in this population.
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Affiliation(s)
- Sarah Nathaniel
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Olachi Oleru
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Nargiz Seyidova
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Lior Levy
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Peter J Taub
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Elan Horesh
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
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Erginel B, Ozdemir B, Karadeniz M, Poyrazoglu S, Keskin E, Soysal FG. Long-term 10-year comparison of girls with congenital adrenal hyperplasia who underwent early and late feminizing genitoplasty. Pediatr Surg Int 2023; 39:222. [PMID: 37386261 DOI: 10.1007/s00383-023-05498-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVES The appropriate time to perform feminizing genitoplasty in patients with congenital adrenal hyperplasia (CAH) with the 46, XX genotype is still debatable. The aim of our study was to evaluate the relationship between age at surgery and long-term surgical outcomes of patients who underwent feminizing genitoplasty. METHODS We retrospectively analyzed 14 patients with CAH and 46, XX genotypes with feminizing genitoplasty (clitoroplasty + vaginoplasty) between 2005 and 2022. The patients were divided into two groups. Group 1 consisted of seven girls (n = 7/14) who have been operated before the age of 2 years. Group 2 consisted of seven girls (n = 7/14) who have been operated after the age of 2 years. The two groups are compared regarding anatomical assessments, overall cosmetic results, need for additional intervention using Creighton's criteria. Additionally, the cosmetical satisfaction of the patients/parents is questioned. RESULTS The mean age of the girls was 32.42 months (10-96 months) during operation time. The mean age of Group 1 patients (n = 7/14) who have been operated before the age of 2 years was 11.71 months (10-19 months). The mean age of Group 2 patients (n = 7/14) who have been operated after the age of 2 years was 53.14 months (36-96 months). The mean follow-up time was 10.57 years (3-18 years). There was no statistically significant difference between those operated on before and after two years in terms of anatomical assessments, overall cosmetic results and patient/parent satisfaction except the need for additional intervention (p = 0.049). In Group1 (operation age < 2 years old), five out of seven (71.42%) patients needed additional major surgery (four urogenital sinus re-mobilization, one redo-clitoroplasty). Those who received additional major surgery were the ones who were not satisfied. In Group 2 (operation age > 2 years old), two patients out of seven patients (28.57%) received major surgery (two redo-urethroplasties) and those patients were not satisfied. When patient/parent satisfaction was compared with additional surgical intervention, as expected, patients'/parents' satisfaction increased as major surgical intervention decreased. This was statistically significant (p = 0.007). The main source of dissatisfaction was repeated surgery among the parents. CONCLUSIONS The possibility of this additional surgical intervention increases, and patient/parent satisfaction decreases in patients below the age of 2 years. The corrective surgeries can be differed until the gender identity of the patient matures and the patient autonomy in deciding whether this surgery should occur.
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Affiliation(s)
- Basak Erginel
- Istanbul Medical Faculty, Department of Pediatric Surgery, Istanbul University, Istanbul, Turkey.
| | - Banu Ozdemir
- Istanbul Medical Faculty, Department of Pediatric Surgery, Istanbul University, Istanbul, Turkey
| | - Meltem Karadeniz
- Istanbul Medical Faculty, Department of Anesthesiology, Istanbul University, Istanbul, Turkey
| | - Sukran Poyrazoglu
- Istanbul Medical Faculty, Department of Pediatric Endocrinology, Istanbul University, Istanbul, Turkey
| | - Erbug Keskin
- Istanbul Medical Faculty, Department of Pediatric Surgery, Istanbul University, Istanbul, Turkey
| | - Feryal Gun Soysal
- Istanbul Medical Faculty, Department of Pediatric Surgery, Istanbul University, Istanbul, Turkey
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Fisher RS, Datillo TM, Baskin LS, Buchanan CL, Cheng EY, Kolon T, Nokoff NJ, Poppas DP, Reyes KJ, Mullins LL, Wisniewski AB. Decisional Regret Among Caregivers of Infants with Differences of Sex Development Reared as Male. J Dev Behav Pediatr 2023; 44:e225-e230. [PMID: 36729523 PMCID: PMC10065892 DOI: 10.1097/dbp.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 10/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Differences of sex development (DSD) are congenital conditions in which individuals are discordant in their chromosomal, phenotypic, and/or gonadal sex. Treatment of DSD can involve surgical intervention to external genitalia to make anatomy seem male-typical (i.e., male genitoplasty). Caregiver-perceived decisional regret regarding young boys with DSD was explored quantitatively and qualitatively. METHOD Participants (N = 39) were caregivers of infants (N = 23) diagnosed with DSD (mean age = 8.9 months, standard deviation = 5.9 months) reared male participating in a longitudinal investigation of psychosocial outcomes. Qualitative data were collected at 6 to 12 months after baseline enrollment to evaluate caregiver decision-making corresponding to levels of regret concerning their child's treatment. All but one infant received genital surgery before caregiver reporting on their decisional regret. Quantitative exploratory analyses evaluated longitudinal predictors of decisional regret at 6 to 12 months. RESULTS When completing a write-in item inquiring about decision-making and potential regret, most caregivers (n = 16, 76%) reported that their child's genital surgery was their first medical decision. Two caregivers referenced gender assignment as a decision point. One-third of caregivers reported some level of decisional regret (33%), with 67% reporting no regret. No hypothesized predictors of decisional regret were statistically significant. CONCLUSION Many caregivers of infants with DSD reared male view genital surgery as a first health care decision. Approximately one-third of caregivers reported some level of decisional regret. Further research is warranted to explore long-term decisional regret; it will be particularly important to investigate the decisional regret of patients with DSD.
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Affiliation(s)
- Rachel S. Fisher
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
| | - Taylor M. Datillo
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
| | - Laurence S. Baskin
- University of California San Francisco Medical Center, Department of Urology, San Francisco, CA, USA
| | - Cindy L. Buchanan
- University of Colorado Anschutz Medical Campus, Department of Psychiatry, Aurora, CO, USA
| | - Earl Y. Cheng
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Urology, Chicago, IL, USA
| | - Thomas Kolon
- Children’s Hospital of Philadelphia, Division of Urology, Philadelphia, PA, USA
| | - Natalie J. Nokoff
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, Division of Endocrinology, Aurora, CO, USA
| | - Dix P. Poppas
- New York Presbyterian Weill Cornell Medicine, Department of Urology, Komansky Children’s Hospital, New York, NY, USA
| | - Kristy J. Reyes
- Cook Children’s Medical Center, Department of Pediatric Urology, Fort Worth, TX, USA
| | - Larry L. Mullins
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
| | - Amy B. Wisniewski
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
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Auer MK, Nordenström A, Lajic S, Reisch N. Congenital adrenal hyperplasia. Lancet 2023; 401:227-244. [PMID: 36502822 DOI: 10.1016/s0140-6736(22)01330-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 05/17/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders leading to multiple complex hormonal imbalances caused by various enzyme deficiencies in the adrenal steroidogenic pathway. The most common type of congenital adrenal hyperplasia is due to steroid 21-hydroxylase (21-OHase, henceforth 21OH) deficiency. The rare, classic (severe) form caused by 21OH deficiency is characterised by life-threatening adrenal crises and is the most common cause of atypical genitalia in neonates with 46,XX karyotype. After the introduction of life-saving hormone replacement therapy in the 1950s and neonatal screening programmes in many countries, nowadays neonatal survival rates in patients with congenital adrenal hyperplasia are high. However, disease-related mortality is increased and therapeutic management remains challenging, with multiple long-term complications related to treatment and disease affecting growth and development, metabolic and cardiovascular health, and fertility. Non-classic (mild) forms of congenital adrenal hyperplasia caused by 21OH deficiency are more common than the classic ones; they are detected clinically and primarily identified in female patients with hirsutism or impaired fertility. Novel treatment approaches are emerging with the aim of mimicking physiological circadian cortisol rhythm or to reduce adrenal hyperandrogenism independent of the suppressive effect of glucocorticoids.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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Kremen J, Harris RM, Aston CE, Perez M, Austin PF, Baskin L, Cheng EY, Fried A, Kolon T, Kropp B, Lakshmanan Y, Nokoff NJ, Palmer B, Paradis A, Poppas D, Reyes KJS, Wolfe-Christensen C, Diamond DA, Tishelman AC, Mullins LL, Wisniewski AB, Chan YM. Exploring Factors Associated with Decisions about Feminizing Genitoplasty in Differences of Sex Development. J Pediatr Adolesc Gynecol 2022; 35:638-646. [PMID: 35948206 PMCID: PMC9701156 DOI: 10.1016/j.jpag.2022.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/24/2022] [Accepted: 08/04/2022] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE Infants with genital development considered atypical for assigned female sex may undergo feminizing genitoplasty (clitoroplasty and/or vaginoplasty) in early life. We sought to identify factors associated with parent/caregiver decisions regarding genitoplasty for their children with genital virilization. DESIGN Longitudinal, observational study SETTING: Twelve pediatric centers in the United States with multidisciplinary differences/disorders of sex development clinics, 2015-2020 PARTICIPANTS: Children under 2 years old with genital appearance atypical for female sex of rearing and their parents/caregivers INTERVENTIONS/OUTCOME MEASURES: Data on the child's diagnosis and anatomic characteristics before surgery were extracted from the medical record. Parents/caregivers completed questionnaires on psychosocial distress, experience of uncertainty, cosmetic appearance of their child's genitalia, and demographic characteristics. Urologists rated cosmetic appearance. For 58 patients from the study cohort with genital virilization being raised as girls or gender-neutral, we compared these data across 3 groups based on the child's subsequent surgical intervention: (i) no surgery (n = 5), (ii) vaginoplasty without clitoroplasty (V-only) (n = 15), and (iii) vaginoplasty and clitoroplasty (V+C) (n = 38). RESULTS Fathers' and urologists' ratings of genital appearance were more favorable in the no-surgery group than in the V-only and V+C groups. Clitorophallic length was greater in the V+C group compared with the V-only group, with substantial overlap between groups. Mothers' depressive and anxious symptoms were lower in the no-surgery group compared with the V-only and V+C groups. CONCLUSIONS Surgical decisions were associated with fathers' and urologists' ratings of genital appearance, the child's anatomic characteristics, and mothers' depressive and anxious symptoms. Further research on surgical decision-making is needed to inform counseling practices.
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Affiliation(s)
- Jessica Kremen
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Rebecca M Harris
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Paul F Austin
- Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Laurence Baskin
- University of California San Francisco Medical Center, UCSF School of Medicine, San Francisco, California
| | - Earl Y Cheng
- Lurie Children's Hospital of Chicago, Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Allyson Fried
- John R. Oishei Children's Hospital, Buffalo, New York
| | - Thomas Kolon
- Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bradley Kropp
- Oklahoma State University, Stillwater, Oklahoma; OKC Kids, Oklahoma City, Oklahoma
| | - Yegappan Lakshmanan
- Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan
| | - Natalie J Nokoff
- Childrens Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Blake Palmer
- Cook Children's Medical Center, University of Oklahoma, College of Medicine, Oklahoma City, Oklahoma
| | - Alethea Paradis
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Dix Poppas
- New York Presbyterian Hospital, Weill Cornell Medical College, New York City, New York
| | - Kristy J Scott Reyes
- Cook Children's Medical Center, University of Oklahoma, College of Medicine, Oklahoma City, Oklahoma
| | - Cortney Wolfe-Christensen
- Cook Children's Medical Center, University of Oklahoma, College of Medicine, Oklahoma City, Oklahoma
| | - David A Diamond
- Golisano Children's Hospital, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Amy C Tishelman
- Boston College, Morrissey College of Arts and Sciences, Boston, Massachusetts
| | | | - Amy B Wisniewski
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Yee-Ming Chan
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Techniques of Primary Vaginoplasty in Young Adults with Differences of Sex Development and Female Identification. J Clin Med 2022; 11:jcm11133688. [PMID: 35806974 PMCID: PMC9267529 DOI: 10.3390/jcm11133688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 02/01/2023] Open
Abstract
Background: The ideal timing of genital surgery in differences/disorders of sex development (DSD) is controversial and differs according to the underlying type of DSD. Increasing numbers of persisting sinus as a result of delayed feminizing genitoplasty in DSD patients require interdisciplinary collaboration of pediatric surgeons/urologists and gynecologists. This study focusses on surgical techniques other than bowel vaginoplasties and results of gender assigning surgery in young adolescents. Methods: Data of adolescent and adult patients treated between 2015 and 2022 were analyzed retrospectively: underlying type of malformation, techniques of vaginoplasty, vaginal length and caliber, possibility of sexual intercourse, and temporary vaginal dilatation. Results: A total of 9 patients received a primary vaginoplasty at a median age of 16.75 years (range 10.3–29.25). The underlying anatomical conditions were persistent urogenital sinus (UGS) in 8 patients (3 patients with CAH, 2 patients with XY-DSD, 1 patient with cloacal malformation and missed UGS, 2 patients with UGS only). One patient had a MURCS association. Surgical techniques were total urogenital mobilization and perineal flap vaginoplasty in 4 patients, modified McIndoe vaginoplasty in 4 patients, and a laparoscopic vaginal pull-through in 1 patient. In a median follow-up of 45 months (2–84), all but 1 patient presented with physiological vaginal length and width. Conclusions: If possible, modern treatment concepts delay gender assigning surgery until the participation of the patient in the decision-making process is possible. Optimal treatment concepts are given by transfer of surgical techniques from pediatric urology/surgery by multidisciplinary teams. Techniques other than bowel vaginoplasties are favorable.
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7
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Fisher RS, Espeleta HC, Baskin LS, Buchanan CL, Chan YM, Cheng EY, Coplen DE, Diamond DA, Nokoff NJ, Palmer BW, Poppas DP, Scott Reyes KJ, Tishelman A, Wolfe-Christensen C, Mullins LL, Wisniewski AB. Decisional regret about surgical and non-surgical issues after genitoplasty among caregivers of female infants with CAH. J Pediatr Urol 2022; 18:27-33. [PMID: 34742644 PMCID: PMC8983419 DOI: 10.1016/j.jpurol.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/24/2021] [Accepted: 10/04/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Caregivers of female infants with congenital adrenal hyperplasia (CAH) often confront complex medical decision-making (e.g., early feminizing genitoplasty). OBJECTIVE This study aimed to evaluate the relevant medical decisions and subsequent decisional regret of caregivers following their child's genitoplasty. STUDY DESIGN Caregivers (N = 55) were recruited from multidisciplinary treatment programs for participation in a longitudinal study. Qualitative data was collected at 6-12 months following feminizing genitoplasty to evaluate caregiver-reported decision points across their child's treatment. Quantitative exploratory analysis evaluated pre-operative predictors of subsequent decisional regret. DISCUSSION When prompted about their decision-making and potential regret, most caregivers (n = 32, 80%) reported that their daughter's genital surgery was their primary medical decision. Specific themes regarding genital surgery included the timing and type of surgery. Most caregivers reported no decisional regret (62%), with 38% reporting some level of regret. Greater pre-operative illness uncertainty predicted heightened decisional regret at follow-up, p = .001. CONCLUSION Two-thirds of caregivers of female infants with CAH reported not regretting their decision-making. Nevertheless, over one-third of caregivers reported some level of regret, suggesting the need for improvements in shared decision-making processes. Many, but not all, families reported that this regret was related to surgical decision-making. Reducing caregiver illness uncertainty (e.g., providing clear information to families) may increase their satisfaction with decision-making. Further research is needed to determine how the evolving care practices surrounding early genitoplasty will impact families.
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Affiliation(s)
- Rachel S Fisher
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
| | - Hannah C Espeleta
- Medical University of South Carolina, College of Nursing, Charleston, SC, USA
| | - Laurence S Baskin
- University of California San Francisco Medical Center, Department of Urology, San Francisco, CA, USA
| | - Cindy L Buchanan
- University of Colorado Anschutz Medical Campus, Department of Psychiatry, Aurora, CO, USA
| | - Yee-Ming Chan
- Boston Children's Hospital, Division of Endocrinology, Department of Pediatrics, Harvard Medical School, Department of Pediatrics, Boston, MA, USA
| | - Earl Y Cheng
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Urology, Chicago, IL, USA
| | - Douglas E Coplen
- St. Louis Children's Hospital, Division of Urologic Surgery, St. Louis, MO, USA
| | | | - Natalie J Nokoff
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, Division of Endocrinology, Aurora, CO, USA
| | - Blake W Palmer
- Cook Children's Medical Center, Department of Pediatric Urology, Fort Worth, TX, USA
| | - Dix P Poppas
- New York Presbyterian Weill Cornell Medicine, Department of Urology, Komansky Children's Hospital, New York, NY, USA
| | - Kristy J Scott Reyes
- Cook Children's Medical Center, Department of Pediatric Urology, Fort Worth, TX, USA
| | | | | | - Larry L Mullins
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA
| | - Amy B Wisniewski
- Oklahoma State University, Department of Psychology, Center for Pediatric Psychology, Stillwater, OK, USA.
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8
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Ellerkamp V, Rall KK, Schaefer J, Stefanescu D, Schoeller D, Brucker S, Fuchs J. Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature. J Sex Med 2021; 18:1797-1806. [PMID: 37057496 DOI: 10.1016/j.jsxm.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/31/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Secondary vaginal stenosis may occur after reconstruction of genital malformations in childhood or after failed vaginal aplasia repair in adults. AIM This study focusses on the results of the surgical treatment of these patients in our multidisciplinary transitional disorders/differences of sex development team of pediatric surgeons and gynecologists. METHODS A retrospective analysis was carried out on adult and female identified disorders/differences of sex development patients with vaginal stenoses treated between 2015 and 2018 in a single center with revision vaginoplasty. The underlying type of malformation, the number and surgical techniques of vaginoplasties in infancy, techniques of revision of the stenotic vagina, vaginal length and caliber, possibility of sexual intercourse, and temporary vaginal dilatation. A review of literature with regard to recommended surgical techniques of revision vaginoplasties was accomplished. OUTCOMES To describe the surgical technique, the main outcome measures of this study are vaginal calipers after revision vaginoplasty as well as ability for sexual intercourse. RESULTS Thirteen patients presented with vaginal stenosis with a median age of 19 years (range 16-31). All patients had one or more different types of vaginoplasties in their medical history, with a median age at first vaginoplasty of 15 months (0-233). Underlying anatomical conditions were urogenital sinus (n = 8), vaginal agenesis (n = 2), persistent cloacae (n = 2), and cloacal exstrophy (n = 1). The main symptoms were disability of sexual intercourse in 13 patients due to stenotic vaginal tissue. The most frequently performed surgical technique was partial urogenital mobilization with a perineal or lateral flaps (n = 10), followed by bowel vaginoplasty (n = 2), in 1 patient a revision vaginoplasty failed due to special anatomical conditions. In a median follow-up of 11 months, all but one patient presented with physiological vaginal length and width, and normal sexual intercourse in those with a partnership. CLINICAL IMPLICATIONS Perineal flap with partial urogenital mobilization should be considered as a treatment of choice in severe cases of distal vaginal stenosis and after multiple failed former vaginoplasties, while bowel vaginoplasty should be reserved only for cases of complete cicatrization or high located stenosis of the vagina. STRENGTHS & LIMITATIONS The strength of this study is the detailed description of several cases while the retrospective character is a limitation. CONCLUSION In patients after feminizing genital repair, perineal flap with partial urogenital mobilization provides a normal anatomical outcome and allows unproblematic sexual intercourse. Ellerkamp V, Rall KK, Schaefer J, et al. Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature. J Sex Med 2021;18:1797-1806.
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Affiliation(s)
- Verena Ellerkamp
- Department of Pediatric Surgery and Pediatric Urology, University Hospital Tuebingen, Tuebingen, Germany.
| | - Kristin Katharina Rall
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Juergen Schaefer
- Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Diana Stefanescu
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Dorit Schoeller
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Sara Brucker
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Joerg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Hospital Tuebingen, Tuebingen, Germany
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9
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Long CJ, Van Batavia J, Wisniewski AB, Aston CE, Baskin L, Cheng EY, Lakshmanan Y, Meyer T, Kropp B, Palmer B, Nokoff NJ, Paradis A, VanderBrink B, Scott Reyes KJ, Yerkes E, Poppas DP, Mullins LL, Kolon TF. Post-operative complications following masculinizing genitoplasty in moderate to severe genital atypia: results from a multicenter, observational prospective cohort study. J Pediatr Urol 2021; 17:379-386. [PMID: 33726972 PMCID: PMC8713352 DOI: 10.1016/j.jpurol.2021.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Differences of sex development (DSD) are congenital conditions in which there is atypical chromosomal, gonadal and/or phenotypic sex. A phenotype of severe genital atypia in patients raised as male is a relatively rare occurrence and standards for management are lacking. Decision making for early surgical planning in these rare cases includes, but is not limited to, degree of atypia, location of testes, and presence of Mϋllerian remnants. In this study we describe surgical approaches and short-term outcomes for masculinizing genitoplasty in moderate to severe genital atypia in young patients raised male, for whom parents opted for early surgery. METHODS This NIH-sponsored study is an ongoing, observational, multicenter investigation assessing medical, surgical and psychological outcomes in children and their parents affected by atypical genitalia due to DSD. Participants were prospectively enrolled from 12 children's hospitals across the United States that specialize in DSD care. Criteria for child enrollment were a Quigley score of 3-6 in those with a 46, XY or 45,X/46, XY chromosome complement, age <3 years with no previous genitoplasty; patients were included independent of whether genitoplasty was performed. Cosmesis was graded according to a 4-point Likert scale and complications per the Clavian-Dindo classification. RESULTS Of the 31 participants, 30 underwent hypospadias repair and 1 patient did not undergo a genitoplasty procedure. The majority of participants (22) received a staged hypospadias repair. Seventeen complications were identified in 12 of the 31 children (41%) at 12 months of follow up. Glans dehiscence and urethrocutaneous fistula were the most common complications. Orchiopexy was performed in 14 (44%) and streak gonads were removed in 4 (13%) participants. Both parents and surgeons reported improved cosmesis after surgery when compared to baseline. CONCLUSION Genitoplasty was chosen by parents for the majority of children eligible for study. No single surgical approach for masculinizing moderate to severe genital ambiguity in young patients with 46, XY or 45,X/46, XY DSD was adopted by all surgeons. Complications occurred in 41% of those who underwent genitoplasty for severe hypospadias. Overall, appearance of the genitals, as determined by parents and surgeons, improved following genitoplasty. Outcomes of early genitoplasty are needed to guide families when making decisions about such procedures for their young children.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dix P Poppas
- New York Presbyterian Hospital/Weill Cornell Medicine, USA.
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Rapp M, Duranteau L, van de Grift TC, Schober J, Hirschberg AL, Krege S, Nordenstrom A, Roehle R, Thyen U, Bouvattier C, Kreukels BPC, Nordenskjold A. Self- and proxy-reported outcomes after surgery in people with disorders/differences of sex development (DSD) in Europe (dsd-LIFE). J Pediatr Urol 2021; 17:353-365. [PMID: 33358555 DOI: 10.1016/j.jpurol.2020.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/14/2020] [Accepted: 12/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgery is performed in many individuals with disorders/differences of sex development (DSD). Irreversibility of some surgical procedures, lack of information about the procedures, and lack of follow-up care for physical and psychological outcomes, lead to wish for more knowledge from both surgeons and patients. After the consensus conference in 2006, multidisciplinary care is provided to a higher degree with psychological support and more restricted surgical procedures. Outcome studies after genital surgery often lack of patient's perspective. OBJECTIVE To describe surgical procedures in relation to diagnosis, to evaluate the outcomes of surgery through genital examination, and through patient's and observer's satisfaction with the anatomical and functional result after genital surgery. STUDY DESIGN In a cross-sectional clinical study performed in six European countries in 2014/15, we have included 500 participants where surgery was performed, from a total of 1040 adolescents (≥16years) and adults with a DSD. Diagnoses included Turner syndrome (n = 301), mixed gonadal dysgenesis (45,XO/46,XY; n = 45), Klinefelter syndrome (n = 218), XYY (n = 1), 46, XY DSD (n = 222) and 46, XX DSD (n = 253). Study protocol included clinical report files, an optional gynecological or urological examination, patient reported outcomes including received surgical interventions, satisfaction with appearance and function after surgery, and impact of the surgical procedure on life. RESULTS Five hundred participants had received genital or breast surgery, with the highest rate in 46, XY DSD and the lowest in Turner syndrome. Altogether; 240 participants had feminizing surgery, 112 had masculinizing surgery, and 217 underwent gonadectomy. Physicians evaluated anatomical appearance at genital examination as poor in less than 10%. Dissatisfaction with anatomical appearance was reported by 22% of the participants, dissatisfaction with function by 20%. Being (very) dissatisfied with anatomical appearance and function was reported by 13% of the study participants. Most participants reported no impact, or positive impact, of the surgical procedures on their lives, but 29% experienced a negative effect of gonadectomy on their life. DISCUSSION There might be a selection bias and/or a recall bias for participating in our studies. Due to poor data quality about surgical procedures performed in the past, we also relied on participants memory about surgical procedures in their past. Ideally, patient reported outcomes should be evaluated both before and after surgical procedures. CONCLUSION A vast majority are satisfied with appearance and function, but still genital or breast surgery have a long-lasting effect on patient's life. Self-reported satisfaction is usually lower than the observer's evaluation regarding both appearance and function.
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Affiliation(s)
- Marion Rapp
- Klinik fur Kinder- und Jugendmedizin, Universitat zu Lubeck, Ratzeburger Allee 160, Lubeck, 23538, Germany.
| | - Lise Duranteau
- Adolescent and Young Adult Gynecology Unit, Centre de Reference des Maladies Rares du Développement Génital, Hôpital Bicêtre, AP.HP Paris Saclay University, 78 rue du General Leclerc, Le Kremlin Bicêtre, 94270, France.
| | - Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Centers, location VUmc, PO Box 7057, Amsterdam. 1007, the Netherlands; Department of Medical Psychology, Amsterdam University Medical Centers, location VUmc, PO Box 7057, Amsterdam, 1007, the Netherlands.
| | - Justine Schober
- UPMC Hamot, Department of Urology, 201 State St. Erie, PA, 16550, USA.
| | - Angelica L Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Department of Gynaecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, 171 76, Sweden.
| | - Susanne Krege
- Kliniken Essen-Mitte, Klinik fur Urologie, Kinderurologie und urologische Onkologie, Evangelische Huyssens Stiftung/Knappschaft GmbH, Essen, 45136, Germany.
| | - Anna Nordenstrom
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, 171 76, Sweden.
| | - Robert Roehle
- Charité - Universitätsmedizin Berlin, Coordinating Center for Clinical Studies, Berlin, 13353, Germany.
| | - Ute Thyen
- Klinik fur Kinder- und Jugendmedizin, Universitat zu Lubeck, Ratzeburger Allee 160, Lubeck, 23538, Germany.
| | - Claire Bouvattier
- Endocrinologie pediatrique, Centre de Reference des Maladies Rares du Développement Génital, Hôpitaux Universitaires Paris Saclay (Bicêtre), 78 rue du General Leclerc, Le Kremlin Bicetre, 94270, France.
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology, Amsterdam University Medical Centers, location VUmc, PO Box 7057, Amsterdam, 1007, the Netherlands.
| | - Agneta Nordenskjold
- Department of Women's and Children's Health and Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Pediatric Surgery, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden.
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